Associate Residency Program Director, Assistant Professor, Emergency
Medicine, Department of Emergency Medicine, Maine Medical Center,
Portland, ME, USA
If tape is necessary for immobilization allergy shots large local reaction generic loratadine 10mg on-line, use low-stick tape instead of adhesive tape to prevent skin tears allergy testing infants buy loratadine 10 mg low price. Because of reduced body fat and poor circulation allergy testing images buy cheap loratadine 10mg, the older patient may be cold even though the room is at a normal warm temperature allergy testing diet order 10mg loratadine visa. The older patient often requires special accommodations during the preliminary stages of an imaging examination 621 allergy symptoms 10mg loratadine sale. The radiographer should keep in mind that the anatomy requested should appear on the final image allergy symptoms with cough cheap 10 mg loratadine otc, while considering the limitations imposed by the musculoskeletal structures of the older patient allergy shots pros cons generic 10 mg loratadine otc. For example allergy testing for babies purchase loratadine 10 mg with amex, radiography examinations of the fingers, hands, wrists, elbows, and distal humerus may be obtained without moving the patient from a chair or requiring the patient to stretch over the end of the imaging table. Some facilities may have an image receptor support, such as a lightweight piece of wood or plexiglass that can rest on the arms of the wheelchair. This provides an ideal method of obtaining upper extremity images when the patient is wheelchair bound. A similar type of image receptor support bench can be used to obtain radiography images of the toes, feet, ankles, lower legs, knees and the distal femur. There are several radiography findings that are consistent with aging, chronic pathology, and the lifestyle choices of many elderly patients. In chest radiography of the elderly, the images may be expected to have calcifications of the great vessels. In radiography images of the spine and pelvis, compression fractures, osteoporosis and osteoarthritis are likely to be evident. Extremity radiography images of geriatric patients are likely to exhibit evidence of gout, osteoporosis, rheumatoid arthritis, and degenerative joint disease. The degree to which people realize that they have memory problems varies greatly from person to person. Some people forget that they are forgetting, while others are extremely aware of their cognitive losses and become depressed. In this stage, the individual may forget what they are talking about in the middle of a sentence. They may ask the same question several times, mixing up words, and speak in an unorganized, garbled way. The third stage of the disease is often recognized when the individual no longer utters words, except when answering direct questions. The radiography-imaging environment poses such a threat because the size of the equipment may appear as a monstrous beast. The radiographer should remember that individuals with dementia are adults who simply have severe memory problems. Radiographers may be able to apply the following information when attempting to obtain quality radiography images on patients with a memory disability. Respect is the first rule in initiating communication with patients during radiography examinations. During the initial introductions, the radiographer respects the individual when using appropriate courtesy titles such as Mr. The radiographer should realize that repeating directions is necessary when the individual has dementia or some type of memory disorder. The first introduction sets the stage, as the radiographer states, who they are and what they intend to do. Individuals with dementia have a shortterm memory that may last no longer than 1 to 3 minutes without any distractions or interruptions. The radiographer can create a non-threatening environment by using a calm and easy going manner when having to repeat directions or questions to affected individuals. The radiographer should expect to have to reintroduce him or herself and remind the patient about what is happening. Using short sentences that convey one thought at a time and waiting for an answer before asking the next question is essential to communicating with someone with dementia or memory impairment. Communication skills used with the dementia patient are similar to those used when imaging children. Being honest and telling the child that you are only going to take a "picture" and that it will not hurt is an important part of the initial introduction. Some specific ways to develop trust include: Use a demonstration doll or animal to show what will happen and how the exam will take place. Also the radiographer may sing a familiar song and talk in a low, calm voice to assure the child. Preparation for pediatric patients include having age appropriate immobilization devices ready if needed and generally attending to as many tasks as possible before bringing the pediatric patient into the imaging examination room. Immobilization and sedation are two methods commonly used when performing radiography imaging examinations on young children. The Imaging Routine An organized approach to completing patient care tasks is critical to providing quality services. Most radiographers establish a personalized routine to avoid omitting an important step or steps. Each radiographer adapts the routine to fit the work area, the examination request, and the patient. The following is a brief review of the essential tasks performed in a basic radiography examination. Obtain the imaging request; Interpret what procedures/examinations need to be completed. Also, the radiographer should check to determine whether there are any restrictions about the patient being in an upright position; Prepare the radiographic room. Check to determine that all radiopaque objects have been removed from the area to be evaluated. Explain the examination to the patient and ask for their cooperation during the examination. Perform the radiography imaging examination; Assist the patient into the initial position and determine approximate exposure factors. Note if adjustments in the exposure factors are required; Move the patient and/or part into final position. It is important for the radiographer to engage the patient in conversation during all aspects of the radiography examination. Appropriate conversation includes talking about the reasons for using immobilization and about the reason for breathing and motion control directions that will be given during the examination. Ergonomics Radiographers often suffer chronic aches and pains from lifting and positioning patients. Shoulder, wrist, and elbow injuries are common among radiographers who use their hands, arms, and shoulders in positioning the patient. Ergonomics is the study of the physiological and psychological relationship between the worker and the workplace, making for a healthier, safer environment. If standing at a computer, keep one foot on the floor while placing the other on a box or shelf, and switch legs often. This reduces stress on the lower back; and, If sitting at the a computer, sit in a cushioned, comfortable chair, keeping your back straight, feet on the floor, keyboard at elbow level and the monitor at eye level. National surveys conducted to document healthcare worker safety concerning lifting patients is one of the most frequently mentioned causes of on-the-job-injury. Staff members were trained to use the equipment and results were dramatic in reducing injuries. Also the pelvic tilt helps to strengthen the muscles used in moving, lifting, and positioning patients. Radiographers are advised to refer to an exercise manual for specifics about toning and strength building exercises. Medical Errors Easily preventable medical errors kill as many as 195,000 people per year in U. To "do no harm", the radiographer can first check and recheck all the steps required to accomplish a specific imaging examination. A major factor in limiting errors in imaging examinations is effective communication between radiographers, patients, and staff. The radiographer can also prevent errors in imaging examinations by following the established protocols and procedures for a particular medical facility. Individual patient circumstances often require that the radiographer adapts the routine procedure for a particular examination but any extreme variation should be explained in the examination documentation. One should never become so overwhelmed that there is no time to check technical factors, patient positioning, or adhere to standard radiation safety measures. Although time is of the essence during imaging examinations, especially trauma care, the radiographer should remember that the time spent on "doing the work right, the first time", will more likely result in the production of diagnostic quality images. A simple yet effective way to limit errors in imaging examinations is to maintain communication between co-workers, patients, physicians, and all support staff. To summarize the importance of preventing errors in imaging examinations, the radiographer should: Review and check all paperwork related to a imaging examination just finished to determine that all documentation is complete before moving on to another patient; Concentrate on the task at hand by focusing on one patient at a time; Read each imaging request thoroughly before preparing for the imaging examination; Develop a routine approach to preparing for each imaging examination; and Review the images to determine if the required facility standards for quality have been met. Obligations to Protect the radiographer has moral, ethical, and legal obligations to protect the public, patients, co-workers, staff, and self from harm while in the service of providing imaging services. All personnel must follow recognized universal practices when participating in or performing imaging examinations. There are unlimited contacts for disease transmission and cross infection among the many people who enter a medical facility. Infection can spread from a single focal point or person of contamination to many other parts of the medical care chain and the general public. Nosocomial infections, often called opportunistic infections, are a group of disease causing organisms that are often drug resistant and extremely pathogenic organisms. These occur primarily in hospitals and medical care settings and result from infections in wounds and in the urinary and upper respiratory tracts. Radiographers are responsible for preventing the spread of microorganisms to others and for protecting themselves from contamination. The total number of infectious organisms can be reduced or diluted to a harmless level by such tasks as hand washing before and after attending each patient, proper disposal of contaminated items, and routine cleaning of imaging equipment and accessories. Radiographers should also practice infection control and follow standard precautions at all times. Medical Equipment As has been mentioned previously, imaging examinations of musculoskeletal structures represents a major percentage of the daily workload in imaging facilities. It is important for the radiographer to recognize common life support and other essential medical equipment 45 that may be within the patient or somehow attached to the patient and must be dealt with during mobile bedside imaging examinations. Tubes, lines, and catheters are essential in treatment of various conditions of the respiratory and circulatory systems. External apparatus such as tubing, clamps, and syringes often lie on or under the patient and the radiographer must use care when positioning the patient to ensure that these are excluded from the images. The patient may have ventilator support tubing, temperature and humidity sensors, or electrocardiogram electrodes and the radiographer should not disturb these during the imaging examination. Pleural devices such as thoracotomy (chest) tubes allow drainage of air (higher chest placement) or fluid (lower chest placement) from the thoracic cavity and allow the lungs to inflate. Such devices consist of a large plastic tube, which is inserted through the chest wall between the ribs. The normally positioned tube lies on the surface of the expanded lung, between the visceral and parietal pleurae. Endotracheal intubation is a lifesaving procedure but can also be life threatening if the tube is incorrectly positioned. In adults, the tip of the tube should be situated approximately 5 cm above the tracheal carina. When advanced too far, the endotracheal tube usually enters the right main bronchus, causing various combinations of hyperinflation and atelectasis of the lungs. Nasogastric tubes and feeding tubes pass though the mediastinum on their route to the stomach and intestines and are usually visible on radiography images. Vascular catheters and various apparatus are now routinely used for monitoring hemodynamic function; for performing hemodialysis; and for administering fluids, medications, and nutrition. Chest radiographs may be requested shortly after initial insertion to determine proper placement and for the presence of a pneumothorax or hemothorax. Ventricular pacing electrodes are used to provide electrical pacing of the heart, in cases of a very slow heart rate, and after open-heart surgery. Implantable access devices (subcutaneous ports) are designed for easy, longterm access to the vascular system or peritoneal cavity. A central venous catheter is used for monitoring pressure of infusion of medication and nutrition. Such devices, over time, can migrate and cause vessel injury and pulmonary infarction. Cardiac devices are used in the treatment of heart disease and include cardiac pacemakers, valve prostheses, and artificial hearts. Heart valve prostheses have been used successfully since the 1960s and consist of either a mechanical or biologic type. Cardiac pacemakers are as common as prosthetic cardiac valves and may be found in people of all ages, but are more commonly found in older adults. The purpose of cardiac pacemakers is to improve cardiac function, reduce the severity of clinical symptoms, and reduce mortality and morbidity. Aortocoronary saphenous vein bypass grafts for direct myocardial revascularization have been used since 1967. These techniques include surgery, coronary artery angioplasty, and coronary artery stent placement. Since sternotomy is the usual surgical approach for surgery, sternal wires fixing the two sternal segments will be seen on chest radiographs. Vascular clips are also used to occlude veins and arteries and will also be visible on chest images. Miscellaneous items that may be visualized in appendicular skeletal images include replacement joint apparatus and fixation devices such as nails, screws, plates, rods, etc. When such items are present, the radiographer is advised to include the entire device on the radiography image. When preparing the patient for musculoskeletal imaging examinations, the radiographer should use caution because catheter movement can introduce skin organisms into the catheter tract and the bloodstream. The radiographer should not touch the insertion site or surrounding skin and should report to nursing personnel on duty if the dressing over the site is loose or the insertion site is exposed. Central lines and catheters may be easily displaced because of tension on the catheter or tubing, so the radiographer should use caution when positioning and moving the patient during radiography examinations. Authorities believe that this number represents only half of the number of actual reported or discovered cases. Child abuse in most states is chargeable under general felony and misdemeanor criminal statutes such as murder, mayhem or assault with intent to maim, assault and battery by means of a dangerous weapon, and assault and battery. Children who are abused or exposed to abuse are at an increased risk of developing stuttering, bedwetting, insomnia, impaired concentration, aggression, and separation anxiety. It is well documented that children who are abused or exposed to abuse are more likely to become an abuser. Most medical facilities have developed policies and procedures for reporting suspected child abuse. The radiologist, referring physician, radiographer, and all medical staff members are critical watchdogs for the signs and symptoms of child abuse. The importance that radiology imaging professionals play in diagnosing child abuse cannot be overstated. Radiological professionals involved in the detection of child abuse and neglect must be 48 familiar with current laws about reporting. Common questions about reporting involve obtaining consent for assessments, documentation in the medical record; filing mandated child abuse reports with state agencies, civil and criminal court actions, privilege, and confidentiality of the information. What procedural requirements exist to fulfill professional responsibility to patients and the state? Among the common exceptions are the following: When an emergency arises and a child is taken to the hospital by police ambulance, the attending physicians may take whatever medical steps are necessary to diagnose and treat the patient, even if the legal guardians are unavailable. When an emancipated minor is married, has children, is a member of the armed forces, or is financially independent and living separate and apart from the parents, the child can often consent to medical intervention. Specific medical issues for which states permit a minor who is pregnant, or a child who has suffered abuse/neglect, to be treated without parental consent. Medical intervention requires the consent of only one parent or guardian, but if there is conflict between parents or guardians, radiological professionals should obtain legal consultation. These statutes have as their primary purpose the identification of child abuse and neglect and, secondarily, the protection of children through state monitoring of families and the 49 provision of services. Many medical facilities have operating guidelines for handling child and elder maltreatment cases. Also, some medical centers may have an interdisciplinary diagnostic team composed of a primary care physician, nurse, social worker, psychiatrist, and radiologists to review and evaluate suspected or confirmed cases of both child and elder abuse. Statutes usually begin by defining groups of mandated reporters; those professionals who must report suspected abuse/neglect to departments of social service. Common mandated groups are teachers, psychologists, social workers, guidance counselors, physicians and nurses, and law enforcement personnel. The basis for notification of state authorities is not knowledge but reasonable suspicion or belief. That is, a person does not need to know that abuse or neglect exists in order to report. A mandated reporter must report if the given medical or social data indicates abuse or neglect. In many states, if a mandated reporter fails to report child abuse when a filing is required, the professional risks imposition of a fine or criminal sanction. Legally, it is always better for a mandated reporter to file an abuse/neglect report, even if the allegation later proves erroneous, than to fail to file. If medical personnel observe a relatively minor injury that is not medically serious but reasonably reflects abuse or neglect, the filing requirement still remains. All states have an immunity provision in the reporting statute, holding the professional free from civil or criminal liability should a filed report not be substantiated. The role of the radiologist and radiographer in cases of suspected abuse is usually that of a consultant acting with limited clinical and laboratory information.
In the case reported allergy symptoms red skin generic loratadine 10mg without a prescription, the history reported 6 previous episodes of choke over a 2-week period allergy nasal drip loratadine 10 mg on-line, each solved by passage of a nasogastric tube allergy symptoms to wheat cheap loratadine 10 mg. Despite several attempts with fluid and paste contrast media allergy forecast wichita falls tx generic 10mg loratadine visa, a distinct narrowing of the oesophagus could not be demonstrated by oesophagography allergy forecast nyc purchase loratadine 10mg with mastercard. The first case was a 47-year-old pony mare fed with soaked pellets and hay because of chronic allergy labs buy discount loratadine 10mg on-line, recurrent episodes of choke allergy forecast ottawa generic 10 mg loratadine free shipping. A stricture was identified in the cervical oesophagus during endoscopy but could not be demonstrated with negative or positive contrast and double contrast oesophagography allergy shots dallas order loratadine 10 mg with amex. In the second case, referred for occasional episodes of choke, a 17 mm nasogastic tube was passed into the stomach with no difficulty and endoscopy revealed an intact oesophageal mucosa. However, contrast oesophagography showed a stricture in the thoracic oesophagus at the level of the tracheal bifurcation. Compared with previous reports, in our cases obstructive symptoms were very evident and severe, i. In both cases, the stricture was evident both endoscopically and radiographically. Besides, double contrast oesophagography was able to clearly demonstrate a very narrow stricture associated with barium accumulation in both cases. Regarding the aetiology, in Case 1 the stricture was possibly due to internal trauma caused by repeated nasogastric intubation. In Case 2, the stricture was probably due to external trauma to the oesophageal wall, caused by accidental intramural phenylbutazone injection. Furthermore, swelling, leukotrichia and the presence of heat and pain on palpation were consistent with a more severe involvement of the oesophageal wall and surrounding tissues. The different treatment options were evaluated according to the case presentation, owner compliance and evaluation of possible side effects. According to the literature, for Case 1 a conservative treatment based on frequent feeding of small quantities of soft food, anti-inflammatory and antimicrobial therapy would have been preferable to surgery (Fubini 2002; Stick 2012). In fact, mucosal stricture formation can occur from as early as the 15th day after mucosal damage, the greatest narrowing happens between Days 30 and 45 but the oesophageal lumen can return to normal by Day 60 under conservative management (Todhunter et al. Unfortunately, due to the narrow stricture, the horse was able to eat only a liquid feed that could not act as a natural stricture dilator. In order to obtain a significant lumen enlargement to allow passage of solid food, a relatively large number of dilating sessions were needed. The owner was made aware that the hospitalisation would be protracted, costs would be elevated and the treatment could be ineffective. As reported in human and small animal medicine, repeated dilating sessions are required in cases of annular stenosis that involve all layers of the oesophageal wall and for long-term management of chronically affected patients (Harai et al. Moreover, it may be assumed that a major component of the resistance to dilation could be exerted by fibrosis of surrounding tissues. This hypothesis seems to be particularly true for Case 2 in which the necrotising effect of phenylbutazone may have resulted in a larger and painful swelling in the left jugular furrow. In this case, the chronicity and type of lesion probably explain the larger number of dilating sessions when compared with Case 1. Furthermore, the long extension of the lesion (15 cm) and reduced length of the balloons used (from 5. According to these considerations, in those cases in which a full thickness involvement and/or an involvement of the surrounding tissues were suspected, an ultrasonographic evaluation of the oesophagus and adjacent region would be advisable in order to reach a definitive prognosis. The use of electrocautery incision of the fibrous tissue followed by dilation has previously been described as a possible treatment of certain types of resistant annular or tortuous strictures in human and small animal medicine (Hordijk et al. However, in the future it may be taken into consideration for chronic dilation-resistant strictures. Despite the large number of dilating sessions, the procedure reported here appeared to be safe and effective. The horses did not show any signs of discomfort during the daily dilating sessions and no complications, such as rupture or perforation of the oesophageal wall, balloon rupture, etc. Preparation of a homemade liquid diet and frequent administration of food were particularly labourious so, when available, commercially available products for horses could be an option. Indeed, more studies are required to standardise the technique in equine patients. The aim of the study is not to investigate any aspect of quinolones or beta-lactam antimicrobials. Authorship the manuscript has been read and approved by all authors who all agreed to the submission of the manuscript to the journal. All named authors critically reviewed its content and approved the final version submitted for publication. This is an interesting case due to the rarity of supernumerary molars in archaeozoological materials, and also because it is the only such case of equid polydontia from the late Byzantium period from that archaeological site. Because of the presence of multiple skeletons in some sites, they are suitable for comparative, quantitative and qualitive analyses (Von den Driesch 1976). These archaeozoological findings also indicate the role that domesticated animals had in cultural development of communities at that time (Lasota-Moskalewska 2005), and how domestication affected the biological characteristics of those animals (Bokonyi 1974; Lasota-Moskalewska 2008). They are also a source of information on diseases of animals closely associated with man (Bartosiewicz 2008; Waldron 2009). However, due to the fact that human consumption remnants prevail in archaeozoological materials, animal remains with possible pathological abnormalities, including skull fragments with anomalies, are very rare (Hillson 2005; Lasota-Moskalewska 2008; Reitz and Wing 2008; Waldron 2009; Pasicka et al. In this paper, the Triadan system of equine dental nomenclature (Fig 2) is used to identify individual teeth (Dixon and du Toit 2011). The well preserved undamaged right mandibular bone had loss of Triadan 406 and the presence of a caudally situated supernumerary molar tooth (Triadan 412). The attached rostral aspect of the left mandibular bone contained an incisor tooth and a portion of the left physiological diastema (Fig 3). The presence of fully developed and erupted canine teeth confirms it was a mature male horse (Fig 1). This specimen is a part of a collection owned by Osteoarchaeology Practice and Research Centre, Department of Anatomy, Faculty of Veterinary Medicine, Istanbul University. The mandible was mined during excavation at the site of Theodosius Harbour at Yenikapi in Istanbul, Turkey. The age of this specimen was estimated by Materials and methods the analysed material consisted of a right-sided mandible (catalogue no. This jaw presents an anomaly in molar dentition uncommon for osteoarchaeological materials, as manifested by the presence of an additional cheek tooth (Lasota-Moskalewska 2008). It is also the only recorded occurrence of polyodontia in Equidae from the Byzantium period at the location in question (Onar et al. Animals in prehistory were characterised by a slower ontogeny rate, compared to current species where there is a faster morphological puberty, manifested by more rapid dental development and closure of growth plates of long bones. Because of the geographical site of recovery of this skull, this horse was possibly an Arabian horse-type breed, whose incisor wear differs from other breeds (Muylle 2011). Additionally, when determining the age of an individual based on dental examinations one should consider that the age norms adopted in archaeozoological research have been established in modern species (Lasota-Moskalewska 2008). Anomalies in dentition occur in both man and animals (Hillson 2005; Reitz and Wing 2008; France 2009; Waldron 2009) and they can be divided into genetic, developmental and acquired in origin (Baker and Brothwell 1980; Hillson 2005). Malocclusion is the most common equine dental disorder and is caused by uneven attrition of the cheek teeth occlusal surface, possibly due to dietary reasons (LasotaMoskalewska 2008). Fig 3: Right mandible of a Byzantine period horse recovered from Theodosius Harbour. The 406 tooth is missing (site indicated by star) 407, 408, 409, 410, 411 (M3) and an overgrown supernumerary tooth (412: arrow) are present. Among the common equine developmental dental abnormalities, one should list the atavistic polydontia (typical), associated with the occurrence of a rudimentary 105/205 tooth at the beginning of the row (wolf tooth, dens lupinus) (Konig and Liebich 2007). Developmental dental abnormalities include anomalies of shape and position of teeth, reduced numbers (hypodontia) or even total absence of teeth (anodontia). Horses can also have displaced polyodontia, exemplified by a dentigerous cyst, found on the dorsal aspect of the skull in horses (Jubb and Kennedy 1963). The true prevalence of equid supernumerary teeth is unknown, but clinical surveys have shown it to occur more commonly in incisors than in cheek teeth (Bokonyi 1974; Dixon et al. Examination of photographs and radiographs of this specimen showed loss of the Triadan 406, although no radiographic or gross anatomic evidence of alveolar disease was evident and so this loss is likely to be an artefactual post mortem loss. Radiography does not show any abnormalities in the overlying 407 or 408 teeth, but confirmed the presence of a localised periostitis of the ventral mandible. In an equid of this age, this swelling is very likely to be due to a local mandibular trauma that occurred many months earlier. The 411 that is normally the most caudal cheek tooth, has a normal occlusal surface, and contains the usual six pulp horns and the normal triangular occlusal shape of a mandibular Triadan 411 (Dixon and du Toit 2011). Lateral radiographs (Fig 2) of this tooth shows a wide reserve crown, and a poorly defined cadual root, as compared to all other cheek teeth roots in this specimen, but this wide reserve crown and delayed cadual root development is a common feature of the equid Triadan 411 mandibular tooth (Dixon and Copeland 1993). Because of the absence of an antagonist tooth, this tooth has overgrown considerably (>1 cm) in height, particularly on its caudal aspect (Fig 2). If the animal had survived, this 412 overgrowth would have increased greatly and eventually caused a severe clinical problem by initially lacerating the tongue and soft tissues of the hard palate region during mastication and even later, possibly penetrating the hard palate (Dixon 2010). Food invariably becomes impacted into diastemata that commonly develop between the supernumerary and adjacent teeth leading to painful periodontal disease (Dixon et al. There is also a lucent area beneath the apex of the supernumerary tooth resembling an eruption cyst, with sclerosis of the adjacent alveolar lining. This supernumerary tooth is also possibly dysplastic because does not taper (rostrocaudally) in an apical direction like a normal cheek tooth (Dixon and du Toit 2011), but instead appears to be slightly wider more apically, even allowing that it is a young tooth. However, its structure is not that of a connated (more than one tooth joined together) supernumerary tooth (Dixon 2010). There is no gross or radiographic evidence that the presence of this additional tooth was causing a clinical problem to this horse and it was very unlikely to have caused its death. Source of funding this research was supported development activity founds Higher Education assigned Medicine, Wroclaw University Sciences. Lohmann Department of Large Animal Clinical Sciences, Western College of Veterinary Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada. This case report describes chronic, intermittent colic in a Quarter Horse filly that had been attributed to chronic idiopathic hepatitis prior to an exploratory laparotomy. A colonic anomaly discovered at surgery became the primary differential for aetiology of the intermittent colic. Euthanasia of the filly and necropsy allowed further examination of the anomaly, where it was determined that the dorsal colon was short compared to the ventral large colon. Case history A 10-month-old Quarter Horse filly presented for investigation of chronic, intermittent colic. The episodes of colic began when the filly was weaned, at age approximately 6 months. Signs observed during episodes of colic included: inappetance, separation from the herd, pawing and prolonged lateral recumbency. The colic would resolve spontaneously and the filly was considered normal in-between episodes, although she did occasionally have non-formed faeces. Apart from weaning, there had been no dietary or housing changes and the other horses and foals on the property were considered normal. She had received treatment per os with fenbendazole (Panacur paste)1 dosed to 10 mg/kg bwt at age 9 and 10 months, prior to the current veterinary involvement. The initial physical examination findings included an elevated heart rate of 68 beats/min, tacky oral mucous membranes and a body condition score of 4/9. Faecal egg count was low with 5 strongyle eggs/g of faeces and no ascarid eggs observed. Further diagnostic work-up, including percutaneous abdominal ultrasonography and abdominocentesis, was declined. The owners reported the colic episodes had continued since the examination at age 10 months, but were sporadic and difficult to predict. In-between episodes, the filly remained bright, alert and responsive and had a good appetite. Serum bile acids were Introduction Chronic, intermittent colic is defined as a horse experiencing more than two episodes of colic in the previous 12 months and may be attributed to a variety of causes (Cohen and Peloso 1996). Some of the risk factors for chronic, intermittent colic include previous celiotomy, advancing age and recent diet change (Cohen and Peloso 1996). Colonic anomalies are extremely rare, but have been reported as a cause of chronic, intermittent colic (Suann and Livesey 1986; Mair 2002). The incidence of congenital anomalies affecting the equine gastrointestinal tract varies from 0. Congenital anomalies affecting the gastrointestinal tract do not always result in signs of colic (Trope and Steel 2010). Defects that have been associated with colic include: abnormalities in the mesocolon or mesentery (Steenhaut et al. Diagnostics including rectal palpation, abdominocentesis, abdominal ultrasonography, liver biopsy and exploratory laparotomy were discussed but declined by the owners. Approximately one month later, the filly presented again following similar signs of colic, with severe signs for 3 days and milder signs for an additional 2 days. At the time of presentation the filly was not obviously uncomfortable and physical examination was within normal limits. Given this information, and the apparent increase in frequency and severity of the colic events, further diagnostics were again recommended and the owners agreed to hospitalisation for further testing. Fig 1: Liver section stained in hematoxylin and eosin, showing mild periportal to bridging fibrosis and mild periportal inflammation. Clinical findings On presentation to the hospital, approximately one week from the previous examination, the filly was bright, alert and responsive, vital parameters were within normal limits and she showed no signs of colic. Results of a serum chemistry panel and complete blood count were similar to previous tests (Table 1). The filly was hospitalised and monitored for 9 days during which time her appetite and faecal output were considered normal, however she did show signs of colic on Days 3, 4 and 5 of hospitalisation. Physical examination revealed mild dehydration (tacky oral mucous membranes) but vital parameters and gastrointestinal borborygmi were within normal limits; rectal examination and abdominal ultrasound examination at this time were unremarkable. Colic signs returned on Days 4 and 5; again vital parameters and gastrointestinal borborygmi were within normal limits and the filly responded to treatment with flunixin meglumine. Diagnostics and post mortem findings In addition to the described diagnostic testing and examinations specific to colic episodes on Days 3, 4 and 5 of hospitalisation, the filly underwent rectal examination on Days 1 and 2 of hospitalisation, abdominal ultrasonography on Days 2 and 3, abdominocentesis on Day 2, liver biopsy on Day 2 and exploratory laparotomy on Day 9. Peritoneal fluid collected by abdominocentesis was grossly normal; total protein concentration was 8 g/l (normal <25 g/l) (Smith and Magdesian 2009) and cytology showed 1. The peritoneal fluid was interpreted as a transudate with low protein and low nucleated cell count. Transcutaneous liver biopsies taken on Day 2 of hospitalisation were negative for bacterial culture. Histological findings from the liver biopsy included mild periportal to bridging fibrosis, mild, chronic-active suppurative periportal hepatitis and mild to moderate biliary hyperplasia. These findings, along with the serial blood work, supported a diagnosis of chronic idiopathic hepatitis (Fig 1). An exploratory laparotomy was scheduled as diagnostics performed to date had not led to a definitive diagnosis and the colic episodes continued. The filly was anaesthetised, positioned in dorsal recumbency and a ventral midline incision made. Once exteriorised it was apparent that the ascending colon was abnormally shaped with an extra flexure located approximately 40 cm orad to the pelvic flexure within the ventral colon (Fig 2). Grossly, the serosa of the section of colon within the extra flexure was normal in colour; peristaltic movements were normal and there was no appreciable variation in diameter. Resection and anastomosis of the apparently extra flexure were offered but declined by the owner and the filly was subjected to euthanasia without recovery from anaesthesia. A complete post mortem examination was performed in which the abnormal flexure located within the length of the left ventral colon was confirmed. The length of each section prior to ingesta removal showed that the caecum was 81 cm from apex to base; the ventral colon was 139 cm and the dorsal colon 119 cm, a full 20 cm shorter than the ventral colon. Multiple sections of the various anatomic portions of the ascending colon were submitted for histological evaluation with no abnormalities found. Histopathology of the liver confirmed findings of the biopsy samples with no definitive diagnosis or aetiological agent identified. Based on ante and post mortem diagnostic findings, the final diagnoses for this filly were idiopathic congenital hypoplasia of the dorsal colon and idiopathic chronic hepatitis. As measurements were not reported (Suann and Livesey 1986; Mair 2002; Trope and Steel 2010) and no normal values are known, it is impossible to compare reports and one must take care not to jump to conclusions regarding a hypoplastic process of the dorsal colon vs. The pathogenesis of colonic anomalies has not been defined (Trope and Steel 2010). However, where congenital pathological conditions are concerned, hypoplasia or dysplasia leading to a decrease in the length of the dorsal colon seems more likely than elongation of the ventral colon. Previous reports have shown that surgical correction of large colon anomalies in the horse may be successful (Suann and Livesey 1986; Mair 2002; Koenig et al. This case points to the need for published references regarding the length of each section of the large colon of the horse. Clinicians and pathologists should consider that hypoplasia of one or more sections of the ascending colon may be the problem when presented with a case of colonic anomaly. Discussion Based on serial blood work and histological evaluation of liver biopsies prior to exploratory laparotomy, the filly described herein was diagnosed with chronic idiopathic hepatitis.
Plafond (Pilon) Fractures Epidemiology Pilon fractures account for 7% to 10% of all tibia fractures allergy on dogs generic loratadine 10 mg without a prescription. Most pilon fractures are a result of high-energy mechanisms; thus allergy zithromax symptoms buy cheap loratadine 10 mg, concomitant injuries are common and should be ruled out allergy medicine easy on stomach discount 10 mg loratadine free shipping. If the fibula remains intact allergy institute buy loratadine 10mg fast delivery, the ankle is forced into varus with impaction of the medial plafond can allergy shots cause jaw pain best loratadine 10 mg. Plantar flexion or dorsiflexion of the ankle at the time of injury results in primarily posterior or anterior plafond injury allergy medicine for children order 10mg loratadine with mastercard, respectively latex allergy symptoms underwear order loratadine 10mg line. Rotational (Low energy): Sporting accident Mechanism is primarily torsion combined with a varus or valgus stress allergy testing for dogs cost loratadine 10 mg cheap. There is usually an associated fibula fracture, which is usually transverse or short oblique. Combined compression and shear Chapter 38 Injuries about the Ankle 493 these fracture patterns demonstrate components of both compression and shear. Because of their high-energy nature, these fractures can be expected to have specific associated injuries: Calcaneus, tibial plateau, pelvis, and vertebral fractures. Clinical Evaluation Most pilon fractures are associated with high-energy trauma; full trauma evaluation and secondary survey is usually necessary. Patients typically present nonambulatory with variable gross deformity of the involved distal leg. Evaluation includes assessment of neurovascular status and evaluation of any associated injuries. The tibia is nearly subcutaneous in this region; therefore, fracture displacement or excess skin pressure may convert a closed injury into an open one. Swelling is often massive and rapid, necessitating serial neurovascular examinations as well as assessment of skin integrity, necrosis, and fracture blisters. Significant damage occurs to the thin soft tissue envelope surrounding the distal tibia as the forces of impact are dissipated. This may result in inadequate healing of surgical incisions with wound necrosis and skin slough if not treated appropriately. Some advise waiting 7 to 10 days for soft tissue healing to occur before planning surgery. Careful preoperative planning is essential with a strategically planned sequence of reconstruction; radiographs of the contralateral side may be useful as a template for preoperative planning. This is used primarily for nondisplaced fracture patterns or severely debilitated patients. Manipulation of displaced fractures is unlikely to result in reduction of intra-articular fragments. Timing of Surgery Surgery may be delayed for several days (7 to 14 days on average) to allow for optimization of soft tissue status, including a diminution of swelling about the ankle, resolution of fracture blisters, and sloughing of compromised soft tissues. High-energy injuries can be treated with spanning external fixation to provide skeletal stabilization, restoration of length and partial fracture reduction while awaiting definitive surgery. The goals of operative fixation of pilon fractures include Surgical Tactic Articular fracture reduction can be achieved percutaneously or through small limited approaches assisted by a variety of reduction forceps, with fluoroscopy to judge fracture reduction. The metaphyseal fracture can be stabilized either with plates or with a nonspanning or spanning external fixator. Grafting of metaphyseal defects with some type of osteoconductive material is indicated. Internal fixation: Open fracture reduction and plate fixation may be the best way to achieve a precisely reduced articular surface. To minimize the complications of plating, the following techniques have been recommended: Surgical delay until definitive surgical treatment using initial spanning external fixation for high-energy injuries Use of small, precontoured, low-profile implants and minifragment screws Avoidance of incisions over the anteromedial tibia Use of indirect reduction techniques to minimize soft tissue stripping Use of percutaneous techniques for plate insertion Joint spanning external fixation: this may be used in patients with significant soft tissue compromise or open fractures. If adequate reduction is obtained, external fixation may be used as definitive treatment. Chapter 38 Injuries about the Ankle 497 Articulating versus nonarticulating spanning external fixation: Nonarticulating (rigid) external fixation are most commonly used, theoretically allowing no ankle motion. Articulating external fixation allows motion in the sagittal plane, thus preventing ankle varus and shortening; application is limited, but theoretically it results in improved chondral lubrication and nutrition owing to ankle motion, and it may be used when soft tissue integrity is the primary indication for external fixation. Fracture reduction is enhanced using thin wires with or without olives to restore the articular surface and maintain bony stability. It is best done after fracture comminution has consolidated and soft tissues have recovered. It is generally performed as a salvage procedure after other treatments have failed and posttraumatic arthritis has ensued. Postoperative Management Initial splint placement in neutral dorsiflexion with careful monitoring of soft tissues. Complications Even when accurate reduction is obtained, predictably excellent outcomes are not always achieved, and less than anatomic reduction can lead to satisfactory outcomes. Soft tissue slough, necrosis, and hematoma: these result from initial trauma combined with improper handling of soft tissues. Secondary closure, skin grafts, or muscle flaps may be required for adequate closure. These complications have been minimized since recognition of the initial soft tissue insult and the strategies to minimize the effects (spanning external fixation, minimally invasive surgery, etc. It has a high incidence with early surgery under unfavorable soft tissue conditions. Late infectious complications may manifest as osteomyelitis, malunion, or nonunion. Posttraumatic arthritis: More frequent with increasing severity of intra-articular comminution; it emphasizes the need for anatomic restoration of the articular surface. Tibial shortening: Caused by fracture comminution, metaphyseal impaction, or initial failure to restore length by fibula fixation. Lateral Ankle Ligament Injuries Sprains of the lateral ligaments of the ankle are the most common musculoskeletal injury in sports. In the United States, it is estimated that one ankle inversion injury occurs each day per 10,000 people. One year after injury, occasional intermittent pain is present in up to 40% of patients. Mechanism of Injury Most ankle sprains are caused by a twisting or turning event to the ankle. Mechanism of injury and the exact ligaments injured depend on the position of the foot and the direction of the stress. With ankle plantar flexion, inversion injuries first strain the anterior talofibular ligament and then the calcaneofibular ligament. With the ankle dorsiflexion and inversion, the injury is usually isolated to the calcaneofibular ligament. With ankle dorsiflexion and external rotation, the injury more likely will involve the syndesmotic ligaments. The syndesmotic ligaments, and in particular the posterior and inferior tibiofibular ligament, can also be injured with the ankle dorsiflexed and the foot internally rotated. Classification Mild ankle sprain: Patients have minimal functional loss, no limp, minimal or no swelling, point tenderness, and pain with reproduction of mechanism of injury. Chapter 38 Injuries about the Ankle 499 Moderate sprain: Patients have moderate functional loss, inability to hop or toe rise on the injured ankle, a limp with walking, and localized swelling with point tenderness. Clinical Evaluation Patients often describe a popping or tearing sensation in the ankle, and they remember the immediate onset of pain. Some patients have an acute onset of swelling around the lateral ankle ligaments and difficulty with weight bearing secondary to pain. Significant physical examination findings may include swelling, ecchymosis, tenderness, instability, crepitus, sensory changes, vascular status, muscle dysfunction, and deformity. The location of the pain helps to delineate the involved ligaments, and it can include the lateral aspect of the ankle, the anterior aspect of the fibula, the medial aspect of the ankle, and the syndesmotic region. The value of stress testing of the lateral collateral ankle ligaments in the acute setting is controversial. At the time of injury, before swelling and inflammation occur, the physician may be able to obtain valuable information by performing an anterior drawer and varus stress examination of the lateral collateral ankle ligaments. In patients who present several hours after injury and who have powerful reflex inhibition, a stress test without anesthesia is unlikely to give valuable clinical information. Injury to the lateral collateral ankle ligaments should be differentiated from other periarticular ligamentous injuries on examination. Significant initial ecchymosis along the heel indicates possible subtalar ligamentous sprain. To evaluate potential syndesmotic injury, the squeeze test and external rotation stress tests are performed (see later). Radiographic Evaluation Most patients should probably undergo radiographic examination to rule out occult foot and ankle injuries with an x-ray series of the foot and ankle. In the acute setting, there probably is little role for performing radiographic stress testing. Nonsurgical approaches are preferred for initial treatment for acute ankle sprains. Once the initial inflammatory phase has resolved, for the less severe ankle sprains (mild to moderate), one can initiate a home rehabilitation program consisting of eversion muscle group strengthening, proprioceptive retraining, and protective bracing while the patient gradually returns to sports and functional activities. For more severe sprains, taping or bracing programs are continued during sports activities for 6 months, and a supervised rehabilitation program used. Patients who continue to have pain in the ankle that does not decrease with time should be reevaluated for an occult osseous or chondral injury. Patients with a history of recurrent ankle sprains who sustain an acute ankle sprain are treated in a manner similar to that described earlier. Treatment Syndesmosis Sprains Syndesmotic sprains account for approximately 1% of all ankle sprains. Injuries to the syndesmotic ligaments are more likely to result in greater impairment than straightforward lateral ankle sprains. In athletes, syndesmotic sprains result in substantially greater lost time from sports activities. Chapter 38 Injuries about the Ankle 501 Classification Diastases of the distal tibiofibular syndesmosis were classified into four types by Edwards and DeLee. Clinical Evaluation Immediately after a syndesmotic ankle sprain, the patient will have well-localized tenderness in the area of the sprain, but soon thereafter, with ensuing swelling and ecchymosis, the precise location of the sprain often becomes obscured. Patients ordinarily present to physicians several hours, if not days, after these injuries, with difficulty in weight bearing, ecchymosis extending up the leg, and marked swelling. The clue to chronic, subclinical syndesmotic sprains is the history of vague ankle pain with push-off and normal imaging studies. The proximal tibiofibular joint should be assessed for tenderness or associated injury. If this maneuver reproduces distal tibiofibular pain, it is likely that the patient has sustained some injury to the syndesmotic region. The external rotation stress test: the patient is seated, with the knee flexed at 90 degrees. If this reproduces pain at the syndesmosis, the test is positive, and the physician should assume, in the absence of bony injuries, that a syndesmotic injury has occured. Similarly, with more chronic problems, calcification of the syndesmosis or posterior tibia may suggest syndesmotic injury. When routine x-rays are negative, and the patient is still suspected of having a syndesmotic injury, stress radiographs can be considered. The examiner should inspect stress radiographs for widening of the medial joint space and tibiofibular clear space on the mortise view and for posterior displacement of the fibula relative to the tibia on the lateral view. Treatment Tibiofibular syndesmotic ligamentous injuries are slower to recover than other ankle ligamentous injuries and may benefit from a more restrictive approach to initial management. This is followed by use of a protective, modified, articulated ankle-foot orthosis that eliminates external rotation stress on the ankle for a variable period, depending on the functional needs and sports activities of the patient. To hold the syndesmotic ligaments while healing, two screws usually placed at the superior margin of the syndesmosis in a nonlagged fashion, from the fibula into the tibia. Achilles Tendon Rupture Epidemiology Most Achilles tendon problems are related to overuse injuries and are multifactorial. Chapter 38 Injuries about the Ankle 503 In a trauma setting, a true rupture is the most common presentation. Delayed or missed diagnosis of Achilles tendon rupture by primary treating physicians is relatively common (up to 25%). It lacks a true synovial sheath and instead has a paratenon with visceral and parietal layers permitting approximately 1. Multiple mesosternal vessels on the anterior surface of the tendon Clinical Evaluation With either partial or complete Achilles tendon rupture, patients typically experience sharp pain, often described as feeling like being kicked in the leg. With a partial rupture, physical examination may only reveal a localized tender area of swelling. With complete rupture, examination normally reveals a palpable defect in the tendon. The Thompson test can be falsely positive when the accessory ankle flexors (posterior tibialis, flexor digitorum longus, flexor hallucis longus muscles, or accessory soleus muscles) are squeezed together with the contents of the superficial posterior leg compartment. Whether operative or nonoperative treatment best achieves these goals remains a matter of controversy. Proponents of surgical repair point to lower recurrent rupture rates, improved strength, and a higher percentage of patients who return to sports activities. Without rupture of the Achilles tendon, squeezing the calf causes active plantar flexion of the foot. With rupture, squeezing the superficial posterior compartment of the leg does not induce plantar flexion of the foot. When major complications, including recurrent ruptures, are compared, both forms of treatment have similar complication rates. Most authors tend to treat active patients who are interested in continuing athletic endeavors with operative treatment and inactive patients or those with other complicating medical factors. Initially, the leg is placed in a splint for 2 weeks, with the foot in plantar flexion to allow hematoma consolidation. Thereafter, a short or long leg cast is placed for 6 to 8 weeks, with less plantar flexion and progressive weight bearing generally permitted at 2 to 4 weeks after injury. After removal of the cast, a heel lift is used while making the transition back to wearing normal shoes. Progressive resistance exercises for the calf muscles are started at 8 to 10 weeks, with a return to athletic activities at 4 to 6 months. Chapter 38 Injuries about the Ankle 505 Patients are informed that attainment of maximal plantar flexion power may take 12 months or more and that some residual weakness is common. Surgical treatment is often preferred when treating younger and more athletic patients. Several different operative techniques have been described, including percutaneous and open approaches. Percutaneous approaches have the advantage of decreased dissection but have historically carried the disadvantages of potential entrapment of the sural nerve and an increased chance of inadequate tendon capture. Open approaches have the intrinsic advantages of permitting complete evaluation of the injury and inspection of final tendon end reapproximation; however, they carry the disadvantages of higher rates of wound dehiscence and skin adhesion problems. The surgical technique uses a medial longitudinal approach to avoid injury to the sural nerve. The paratenon is carefully dissected, and sutures are placed in each tendon end for tendon reapproximation. Postoperative management consists of a partial weight-bearing or weight bearing as tolerated in a short leg cast or boot for 6 to 8 weeks. As with nonoperatively treated patients, progressive resistance exercises are started at 8 to 10 weeks, with a return to sports at 4 to 6 months. Newer techniques and stronger sutures have led to more accelerated rehab protocols. With distal ruptures or sleeve avulsions, an open technique and reattachment of the tendon to the calcaneus is performed. Peroneal Tendon Subluxation Subluxation and dislocation of the peroneal tendons are uncommon and usually result from sports activities. They normally result from forced dorsiflexion or inversion and have been described principally in skiers when they dig the tips of the skis into the snow and create a sudden deceleration force with dorsiflexion of the ankle within the ski boot. The injury is easily misdiagnosed as an ankle sprain, and it can result in recurrent or chronic dislocation. Presentation is similar to that of a lateral ankle sprain with lateral ankle swelling, tenderness, and ecchymosis. The anterior drawer test is negative, and the patient has discomfort and apprehension with resisted eversion of the foot. Radiographic evaluation of a patient with peroneal tendon subluxation or dislocation may reveal a small fleck of bone off the posterior aspect of the lateral malleolus, which is best seen on the internal oblique or mortise view. Treatment When the initial reduction of dislocated tendons is stable, nonoperative techniques can be successful. Management consists of immobilization in a well-molded cast with the foot in slight plantar flexion and mild inversion in an attempt to relax the superior peroneal retinaculum and to maintain reduction in the retrofibular space. When the diagnosis is made on a delayed basis or the patient presents with recurrent dislocations, operative treatment is considered because nonoperative measures are unlikely to work. Surgical alternatives include transfer of the lateral Achilles tendon sheath, fibular osteotomy to create a deeper groove for the tendons, rerouting of the peroneal tendons under the fibulocalcaneal ligament, or simple reconstructive repair of the superior peroneal retinaculum with relocation of the tendons.
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The somatic (general) sensory fibers transmit sensations of touch allergy forecast reston va cheap 10 mg loratadine overnight delivery, pain allergy shots alcohol purchase loratadine 10 mg without a prescription, temperature allergy forecast killeen cheap 10 mg loratadine amex, and position from sensory receptors allergy medicine and grapefruit juice generic loratadine 10mg visa. The somatic motor fibers permit voluntary and reflexive movement by causing contraction of skeletal muscles allergy jefferson city mo discount loratadine 10mg overnight delivery, such as occurs when one touches a candle flame allergy medicine patch discount 10mg loratadine with amex. Early in development allergy vs flu loratadine 10mg online, the spinal cord and vertebral (spinal) canal are nearly equal in length allergy medicine koger purchase 10mg loratadine with mastercard. The canal grows longer, so spinal nerves have an increasingly longer course to reach the intervertebral foramen at the correct level for their exit. The remaining spinal nerves, seeking their intervertebral foramen of exit, form the cauda equina. The anterior rami supply nerve fibers to the anterior and lateral regions of the trunk and upper and lower limbs. The posterior rami supply nerve fibers to synovial joints of the vertebral column, deep muscles of the back, and overlying skin. Visceral reflexes regulate blood pressure and chemistry by altering such functions as heart and respiratory rates and vascular resistance. Visceral sensation that reaches a conscious level is generally categorized as pain that is usually poorly localized and may be perceived as hunger or nausea. Most visceral/reflex (unconscious) sensation and some pain travel in visceral afferent fibers that accompany the parasympathetic fibers retrograde. Most visceral pain impulses (from the heart and most organs of the peritoneal cavity) travel along visceral afferent fibers accompanying sympathetic fibers. In general, the effects of parasympathetic stimulation are anabolic (promoting normal function and conserving energy). Its fiber (axon) synapses on the cell body of a postsynaptic (postganglionic) neuron, the second neuron in the series. Courses taken by sympathetic motor fibers Presynaptic fibers all follow the same course until they reach the sympathetic trunks. Fibers involved in innervating abdominopelvic viscera follow path 4 to prevertebral ganglion via abdominopelvic splanchnic nerves. The two schemes are similar in the trunk but differ in the limbs, where both are presented. The unilateral area of skin innervated by the general sensory fibers of a single spinal nerve is called a dermatome. From clinical studies of lesions in the posterior roots or spinal nerves, dermatome maps have been devised that indicate the typical pattens of innervation of the skin by specific spinal nerves. The unilateral muscle mass receiving innervation from the somatic motor fibers conveyed by a single spinal nerve is a myotome. Each skeletal muscle is innervated by the somatic motor fibers of several spinal nerves; therefore, the muscle myotome will consist of several segments. The muscle myotomes have been grouped by joint movement to facilitate clinical testing. The hip joint is disarticulated in B to demonstrate the acetabulum of the hip bone and the entire head of the femur. Somatic motor (general somatic efferent) fibers transmit impulses to skeletal (voluntary) muscles. The unilateral muscle mass receiving innervation from the somatic motor fibers conveyed by a single spinal nerve is a myotome. Each skeletal muscle is usually innervated by the somatic motor fibers of several spinal nerves; therefore, the muscle myotome will consist of several segments. The muscle myotomes have been grouped by joint movement to facilitate clinical testing. A myotatic (stretch) reflex is an involuntary contraction of a muscle in response to being stretched. The cutaneous innervation of the lower limb reflects both the original segmental innervation of the skin via separate spinal nerves in its dermatomal pattern. In B, the medial sural cutaneous nerve (sural is Latin for calf) is joined between the popliteal fossa and posterior aspect of the ankle by a communicating branch of the lateral sural cutaneous nerve to form the sural nerve. During early development, the trunk is divided into segments (metameres) that correspond to , and receive innervation from, the corresponding spinal cord segments. During the 4th week of development, the upper limb buds appear as elevations of the C5 to T1 segments of the ventrolateral body wall. Following the cranial-to-caudal pattern of development the lower limb buds appear about a week later (5th week). The lower limb buds grow laterally from broader bases formed by the L2 to S2 segments. The distal ends of the limb buds flatten into paddlelike hand plates and foot plates that are elongated in the craniocaudal axis. Initially, both the thumb and the great toe are on the cranial sides of the developing hand and foot, directed superiorly, with the palms and soles directed anteriorly. Where gaps develop between the precursors of the long bones (future elbow and knee joints), flexures occur. At first, the limbs bend anteriorly, so that the elbow and knee are directed laterally, causing the palm and sole to be directed medially (toward the trunk). By the end of the 7th week, the proximal parts of the upper and lower limbs undergo a 90-degree torsion around their long axes, but in opposite directions, so that the elbow becomes directed caudally and the knee cranially. In the lower limb, the torsion of the proximal limb is accompanied by a permanent pronation (twisting) of the leg, so that the foot becomes oriented with the great toe on the medial side. The dermatome pattern of the lower limb according to Foerster (1933) is preferred by many because of its correlation with clinical findings. The dermatome pattern of the lower limb according to Keegan and Garrett (1948) is preferred by others for its aesthetic uniformity and obvious correlation with development. Although depicted as distinct zones, adjacent dermatomes overlap considerably, except along the axial line. If a main channel is slowly occluded, the smaller alternate channels can usually increase in size, providing a collateral circulation that ensures the blood supply to structures distal to the blockage. Although only the anterior and posterior tibial veins are depicted as paired structures in this schematic illustration, typically in the limbs deep veins occur as paired, continually interanastomosing accompanying veins (L. Blood is continuously shunted from these superficial veins in the subcutaneous tissue to deep veins via the perforating veins. Vein grafts obtained by surgically harvesting parts of the great saphenous vein are used to bypass obstructions in blood vessels. When part of the vein is used as a bypass, it is reversed so that the valves do not obstruct blood flow. Because there are so many anastomosing leg veins, removal of the great saphenous vein rarely affects circulation seriously, provided the deep veins are intact. Muscular compression of deep veins assists return of blood to the heart against gravity. Varicose veins form when either the deep fascia or the valves of the perforating veins are incompetent. This allows the muscular compression that normally propels blood toward the heart to push blood from the deep to the superficial veins. The lymphatic vessels along the great saphenous vein drain into the superficial inguinal lymph nodes; those along the small saphenous vein drain into the popliteal lymph nodes. Lymph from the superficial inguinal nodes drains to the deep inguinal and external iliac nodes. Lymph from the popliteal nodes ascends through deep lymphatic vessels accompanying the deep blood vessels to the deep inguinal nodes. Abrasions and minor sepsis, caused by pathogenic microorganisms or their toxins in the blood or other tissues, may produce slight enlargement of the superficial inguinal nodes (lymphadenopathy) in otherwise healthy people. Observe the arrangement of the nodes: a proximal chain parallel to the inguinal ligament (superolateral and superomedial superficial inguinal lymph nodes) and a distal chain on the sides of the great saphenous vein (inferior superficial inguinal lymph nodes). Efferent vessels leave these nodes and pass deep to the inguinal ligament to enter the external iliac nodes. Some of the lymphatic vessels traverse the femoral canal, and others ascend alongside the femoral artery and vein, some inside the femoral sheath, and some outside it. Anterior skin and subcutaneous tissue have been removed to reveal the deep fascia of the thigh (fascia lata) and leg (crural fascia). The iliotibial tract serves as a common aponeurosis for the gluteus maximus and tensor fasciae latae muscles. The fascial compartments of the thigh (C) and leg (D) are demonstrated in transverse section. The fascial compartments contain muscles that generally perform common functions and share common innervation, and contain the spread of infection. While both thigh and leg have anterior and posterior compartments, the thigh also includes a medial compartment and the leg a lateral compartment. Trauma to muscles and/or vessels in the compartments may product hemorrhage, edema, and inflammation of the muscles. Because the septa, deep fascia, and bony attachments firmly bound the compartments, increased volume resulting from these processes raises intracompartmental pressure. In compartment syndromes, structures within or distal to the compressed area become ischemic and may become permanently injured. A fasciotomy (incision of bounding fascia or septum) may be performed to relieve the pressure in the compartment and restore circulation. The arteries are branches of the femoral artery, and the veins are tributaries of the great saphenous vein. The femoral sheath contains the femoral artery, vein, and lymph vessels, but the femoral nerve, lying posterior to the iliacus fascia, is outside the femoral sheath. The boundaries of the femoral triangle are the inguinal ligament superiorly (base of triangle), the medial border of the sartorius (lateral side), and the lateral border of the adductor longus (medial side). The point at which the lateral and medial sides converge inferiorly forms the apex. Retroinguinal passage between the inguinal ligament anteriorly and the bony pelvis posteriorly. The iliopsoas muscle, the femoral nerve, artery, and vein, and the lymphatic vessels draining the inguinal nodes pass deep to the inguinal ligament to enter the anterior thigh or return to the trunk. Pulsations of the femoral artery can be felt distal to the inguinal ligament, midway between the anterior superior iliac spine and the pubic tubercle. Portions of the sartorius muscle, femoral vessels, and femoral nerve have been removed revealing the floor of the femoral triangle, formed by the iliopsoas laterally and the pectineus medially. At the apex of the triangle the femoral vessels, saphenous nerve, and the nerve to the vastus medialis pass deep to the sartorius into the adductor (subsartorial) canal. The central portions of the muscle bellies of the sartorius, rectus femoris, pectineus, and adductor longus muscles have been removed. Weakness of the vastus medialis or vastus lateralis, resulting from arthritis or trauma to the knee joint, for example, can result in abnormal patellar movement and loss of joint stability. The sartorius, gracilis, and semitendinosus muscles form an inverted tripod arising from three different components of the hip bone. These muscles course within three different compartments, perform three different functions, and are innervated by three different nerves yet share a common distal attachment. All three tendons become thin and aponeurotic and are collectively referred to as the pes anserinus. The gracilis is a relatively weak member of the adductor group and hence can be removed without noticeable loss of its actions on the leg. Surgeons often transplant the gracilis, or part of it, with its nerve and blood vessels to replace a damaged muscle in the hand, for example. The femoral artery lies between two motor territories: that of the obturator nerve, which is medial, and that of the femoral nerve, which is lateral. No motor nerve crosses anterior to the femoral artery, but the twig to the pectineus muscle crosses posterior to the femoral artery. The nerve to the vastus medialis muscle and the saphenous nerve accompany the femoral artery into the adductor canal. The saphenous nerve and artery and their anastomotic accompanying vein emerge from the canal distally between the sartorius and gracilis muscles. The deep artery of the thigh arises approximately 4 cm distal to the inguinal ligament, lies posterior to the femoral artery, and disappears posterior to the adductor longus muscle. It supplies the thigh through the medial and lateral circumflex femoral branches and the perforating arteries that pass through the adductor magnus muscle on their way to the posterior aspect of the thigh. Dissection showing the iliotibial tract, a thickening of the fascia lata, which serves as a tendon for the gluteus maximus and tensor fasciae latae. The iliotibial tract attaches to the anterolateral (Gerdy) tubercle of the lateral condyle of the tibia. Superficial dissection of muscles of gluteal region and posterior thigh (hamstring muscles consisting of semimembranosus, semitendinosus, and biceps femoris). Hamstring strains (pulled and/or torn hamstrings) are common in running, jumping, and quick-start sports. The muscular exertion required to excel in these sports may tear part of the proximal attachments of the hamstrings from the ischial tuberosity. The adductor magnus is a large muscle with two parts: one belongs to the adductor group and the other to the hamstring group. The adductor part is innervated by the obturator nerve and the hamstring part by the tibial portion of the sciatic nerve. The trochanteric bursa separates the superior fibers of the gluteus maximus from the greater trochanter of the femur. Proximal Attachmenta Muscle (red) Distal Attachmenta (blue) Innervationb Main Actions Table 5. Proximal Distal Attachmenta (blue) Innervationb Main Actions Attachmenta Musclea (red) Table 5. The gluteus maximus muscle is split superiorly and inferiorly, and the middle part is excised; two cubes remain to identify its nerve. The gluteus maximus is the only muscle to cover the greater trochanter; it is aponeurotic and has underlying bursae where it glides on the trochanter (trochanteric bursa) and the aponeurosis of the vastus lateralis muscle (gluteofemoral bursa). Diffuse deep pain in the lateral thigh region, especially during stair climbing or rising from a seated position, may be caused by trochanteric bursitis. This type of friction bursitis is characterized by point tenderness over the greater trochanter; however, the pain radiates along the iliotibial tract. Injections can be made safely only into the superolateral part of the buttock, avoiding injury to the sciatic and gluteal nerves. The proximal three quarters of the gluteus maximus muscle is reflected, and parts of the gluteus medius and the three hamstring muscles are excised. The superior gluteal vessels and nerves emerge superior to the piriformis muscle; all other vessels and nerves emerge inferior to it. When the weight is borne by one limb, the muscles on the supported side fix the pelvis so that it does not sag to the unsupported side, keeping the pelvis level. When the right abductors are paralyzed, owing to a lesion of the right superior gluteal nerve, fixation by these muscles is lost and the pelvis tilts to the unsupported left side (positive Trendelenburg sign). In the anatomical position the tip of the coccyx lies superior to the level of the ischial tuberosity and inferior to that of the ischial spine. The lateral border of the sciatic nerve lies midway between the lateral surface of the greater trochanter and the medial surface of the ischial tuberosity. The obturator internus is located partly in the pelvis, where it covers most of the lateral wall of the lesser pelvis. It leaves the pelvis through the lesser sciatic foramen, makes a right-angle turn, becomes tendinous, and receives the distal attachments of the gemelli before attaching to the medial surface of the greater trochanter (trochanteric fossa). The obturator externus extends from the external surface of the obturator membrane and surrounding bone of the pelvis to the posterior aspect of the greater trochanter, passing directly under the acetabulum and neck of the femur. Paresthesia radiates to the foot because of anesthesia of the plantar nerves, which are terminal branches of the tibial nerve derived from the sciatic nerve. In the approximately 12% of people in whom the common fibular division of the sciatic nerve passes through the piriformis, this muscle may compress the nerve. In A: the head of the femur is exposed just medial to the iliofemoral ligament and faces superiorly, medially, and anteriorly. At the site of the subtendinous bursa of psoas, the capsule is weak or (as in this specimen) partially deficient, but it is guarded by the psoas tendon. In C: the fibers of the capsule spiral to become taut during extension and medial rotation of the femur. The synovial membrane protrudes inferior to the fibrous capsule and forms a bursa for the tendon of the obturator externus muscle. Note the large subtendinous bursa of the obturator internus at the lesser sciatic notch, where the tendon turns 90° to attach to the greater trochanter. The acetabular labrum is attached to the acetabular rim and transverse acetabular ligament and forms a complete ring around the head of the femur. The ligament of the head of the femur lies between the head of the femur and the acetabulum. These fibers are attached superiorly to the pit (fovea) on the head of the femur and inferiorly to the transverse acetabular ligament and the margins of the acetabular notch. The artery of the ligament of the head of the femur passes through the acetabular notch and into the ligament of the head of the femur. In the anatomical position, the anterior superior iliac spine and pubic tubercle are in the same coronal plane, and the ischial spine and superior end of the pubic symphysis are in the same horizontal plane; the internal aspect of the body of the pubis faces superiorly, and the acetabulum faces inferolaterally.
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